Fillable Form 2.: Request for Portability (University of Texas System)

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Form 2.: Request for Portability (University of Texas System)

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Request for Portability
R0
40119 | Z6060 TX
Mail to Blue Cross and Blue Shield of Texas at:
Attn: Department 6006
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Page 1 of 2
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance
Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross
and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Does Employee have: Voluntary Life:
Voluntary Dependent Life:
If your Insurance benefit terminates, you are eligible to continue your Voluntary Life, Voluntary Dependent Life coverage. You must
apply for the continuation within 31 days of the date of termination of coverage. For information about the maximum amount you may
continue, see your certificate.
To apply:
1.
Complete Part 2 of this application for portability. Be sure that your employer has completed Part 1. Premium rates and instructions
for figuring your premium are shown on the back of this form.
2.
Mail completed application together with your check or money order for the first modal premium within 31 days of termination of
coverage to the address indicated on the back.
Signature of Person Authorized to Certify for Group
Billing Mode (Select one)
I have read the above questions and answers and hereby declare that they are complete and true to the best of my knowledge and belief. I further
agree that while my eligibility to continue this coverage under the terms of the Group Insurance Policy is being determined, the company may deposit
the payment submitted with this application. If I am not eligible to continue my Group Insurance, the sole obligation of the company shall be to refund
the above payment.
If two or more primary beneficiaries are named, and you do not list benefit percentages, proceeds will be paid in equal shares to the named primary beneficiaries who
survive you. If no primary beneficiary survives you, proceeds will be paid to the contingent beneficiary(ies). If you list benefit percentages, the total must be 100%.
Employee Spouse
I wish to continue:
Part 2 TO BE COMPLETED BY INSURED Please type or print with ball point pen
In accordance with and subject to all the terms and conditions of the portability provision contained in my certificate, I elect to continue
my coverage under the Group Policy and agree to pay for the coverage(s) indicated below.
Beneficiary Designation
First Name Last Name Date of Birth Social Security Number
Relationship
Benefit %
(Primary) %
(Primary) %
(Contingent) %
(Contingent) %
Part 1 TO BE COMPLETED BY EMPLOYER (A copy of original approved Evidence of Insurability must be submitted with this application)
Group Number
Name of Employer Insurance Class for Basic Life Coverage:
Date Employment Terminated Date Coverage Terminated Last Day of Actual Work Annual Salary for Basic Life Coverage (if salary based)
Amount $
Date
Name (Last) Benefits ID Number
Sex
Phone Number
Street Address City State Zip Code
Date of Birth
Last Date of Active Work Spouse Name (Last) Spouse Sex Spouse Date of Birth
Voluntary Life
I wish to exercise the Voluntary Life Additional Purchase Option
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR
THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERTO, COMMITS A FRADULENT INSURANCE ACT,
WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALITIES.
NoYes
Amount $
NoYes
Does Spouse have: Voluntary Life:
Voluntary Dependent Life:
Amount $
NoYes
Amount $
NoYes
(First) (MI)
(First)
Voluntary Dependent Life
Amount $
Yes No
Amount $
Yes No
Amount $
Yes No
Amount $
Yes No
Amount $
Yes No
Quarterly
Semi-Annual
Annual
Employee
Signature
Date
Spouse
Signature
Date
GFZ71778
The University of Texas System
R0
40119 | Z6060 TX
Mail to Blue Cross and Blue Shield of Texas at:
Attn: Department 6006
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Page 2 of 2
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of
Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols
are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Example
Employee wants to exercise the Portability Option and continue his Voluntary Term Life Insurance for $100,000, his spouse’s Voluntary
Term Life Insurance of $10,000 and his Voluntary Dependent Life. The employee is 54 years old and his spouse is 49 and they are
both non-tobacco users. The employee wants to be billed quarterly.
Portability Premium Calculation Worksheet
You may continue an amount up to the full amount of your Voluntary Term Life benefit without evidence of insurability. To calculate your
premium find the applicant’s attained age and the corresponding basic quarterly premium per $1,000 from the columns below. If you
and/or your spouse have used cigarette or tobacco products within the last two years, the tobacco rates should be used in
calculating the first modal premium. Multiply this premium by the number of thousands of dollars of insurance you plan to continue.
Voluntary Life Rates
Quarterly Premiums (per $1,000)
Attained Age Non-Tobacco Tobacco
Under 30
$0.45
$0.87
30-34
$0.51
$0.93
35-39
$0.72
$1.26
40-44 $1.23 $2.01
45-49 $1.71 $3.75
50-54 $2.85 $6.09
55-59 $4.95
$11.01
60-64 $7.77 $13.44
Coverage terminates at age 65 for groups with
effective dates of 9/1/08 or later
Voluntary Dependent Life Rates per Family per Quarter:
$5,000 Benefit - Family $3.00
$10,000 Benefit - Family $6.00
Employee $2.85 X 100,(000) = $285.00
Spouse $1.71 X 10,(000) = 17.10
Voluntary Dependent Life
3.00
Total premium due each quarter $305.10
Your Calculations
Table # Thousands Quarterly
Rate X of Coverage = Premium
Employee
Spouse
X
Voluntary Dependent Life
Mail to:
Blue Cross and Blue Shield of Texas
Attn: Department 6006
P.O. Box 7070
Downers Grove, IL 60515
Questions: 1-866-628-2606
5,000
=
X
X
=
=
=
$21.63$12.27
65-69
TobaccoNon-TobaccoAttained Age
Coverage terminates at age 70 for groups with
effective dates between 4/1/03-8/31/08.
Group policyholder effective date prior to 4/1/03
$34.50$19.65
70-74
$57.90$34.80
75 and Over
Request for Portability
Administrative Office: 701 E. 22nd Street, Lombard, IL 60148
Fraud Notices
The laws of some states require us to furnish you with the following notice:
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name
of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and
Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
R
040119 I Z6291_LC
Page 1 of 2
Maryland: Any person who knowingly and willingly presents
a false or fraudulent claim for payment of a loss or benefit or
who knowingly and willfully presents false information in an
application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Virginia: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits.
FOR APPLICATIONS AND CLAIMS:
Colorado: It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance, and civil damages.
Any insurance company or agent of an insurance company
who knowingly provides false, incomplete, or misleading
facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award
payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of
regulatory agencies.
District of Columbia: WARNING: It is a crime to provide
false or misleading information to an insurer for the purpose
of defrauding the insurer or any other person. Penalties
include imprisonment and/or fines. In addition, an insurer
may deny insurance benefits if false information materially
related to a claim was provided by the applicant.
Florida: Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim or
an application containing any false, incomplete, or
misleading information is guilty of a felony of the third degree.
Hawaii: For your protection, Hawaii law requires you be
informed that presenting a fraudulent claim for payment of a
loss or benefit is a crime punishable by fines or
imprisonment, or both.
Kentucky: Any person who knowingly and with intent to
defraud any insurance company or other person files an
application for insurance or a statement of claim containing
any materially false information or conceals, for the purpose
of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Louisiana: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement
in prison.
Maine & Washington: It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of insurance
benefits.
New Mexico: Any person who knowingly presents a false
or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to civil
fines and criminal penalties.
Ohio: Any person who, with intent to defraud or
knowingly that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false
or deceptive statement is guilty of insurance fraud.
Oklahoma: Any person who knowingly, with intent to
injure, defraud or deceive any insurer, makes a claim for
the proceeds of an insurance policy containing false,
incomplete or misleading information is guilty of a felony.
Pennsylvania: Any person who knowingly and with intent
to defraud any insurance company or other person files
an application for insurance or statement of claim
containing any materially false information or conceals for
the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and
civil penalties.
Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a
loss or any other benefit, or presents more than one claim
for the same damage or loss, shall incur a felony and,
upon conviction, shall be sanctioned for each violation
with the penalty of a fine of not less than five thousand
dollars($5,000) and not more than ten thousand dollars
($10,000), or a fixed term of imprisonment for three (3)
years, or both penalties. Should aggravating
circumstances be present, the penalty thus established
may be increased to a maximum of five (5) years, if
extenuating circumstances are present, it may be reduced
to a minimum of two (2) years.
Rhode Island: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines
and confinement in prison.
Tennessee: It is a crime to knowingly provide false
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits.
Alabama: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application
for insurance is guilty of a crime and may be subject
to restitution fines or confinement in prison, or any
combination thereof.
Administrative Office: 701 E. 22nd Street, Lombard, IL 60148
Fraud Notices
The laws of some states require us to furnish you with the following notice:
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name
of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and
Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
R
040119 I Z6291_LC
Page 2 of 2
FOR CLAIMS ONLY:
Idaho: Any person who knowingly, and with intent
to defraud or deceive any insurance company,
files a statement or claim containing false,
incomplete, or misleading information is guilty of a
felony.
Alaska: A person who knowingly and with intent
to injure, defraud, or deceive an insurance
company files a claim containing false,
incomplete, or misleading information may be
prosecuted under state law.
Arizona: For your protection, Arizona law
requires the following statement to appear on this
form. Any person who knowingly presents a false
or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
Arkansas: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in
an application for insurance is guilty of a crime
and may be subject to fines and confinement in
prison.
California: For your protection California law
requires the following to appear on this form. Any
person who knowingly presents false or fraudulent
claim for the payment of a loss is guilty of a crime
and may be subject to fines and confinement in
state prison.
Delaware: Any person who knowingly, and with
intent to injure, defraud or deceive any insurer,
files a statement of claim containing any false,
incomplete or misleading information is guilty of a
felony.
Indiana: A person who knowingly and with intent
to defraud an insurer files a statement of claim
containing any false, incomplete, or misleading
information commits a felony.
Minnesota: A person who files a claim with intent to
defraud or helps commit a fraud against an insurer
is guilty of a crime.
New Hampshire: Any person who, with a
purpose to injure, defraud or deceive any
insurance company, files a statement of claim
containing any false, incomplete or misleading
information is subject to prosecution and
punishment for insurance fraud, as provided in
RSA 638:20.
New Jersey: Any person who knowingly files a
statement of claim containing any false or
misleading information is subject to criminal
and civil penalties.
Texas: Any person who knowingly presents a
false or fraudulent claim for the payment of a
loss is guilty of a crime and may be subject to
fines and confinement in state prison.
Massachusetts: Any person who knowingly
presents a false or fraudulent claim for
payment of a loss or benefit or knowingly
presents false information in an application for
insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FOR APPLICATIONS ONLY:
New Jersey: Any person who includes any
false or misleading information on an
application for an insurance policy is subject to
criminal and civil penalties.
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Form 2.: Request for Portability (University of Texas System)

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Completed 13 January 2021

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